Healthcare Provider Details

I. General information

NPI: 1265614168
Provider Name (Legal Business Name): MICHAEL SORACE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2007
Last Update Date: 02/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 W SAN ANTONIO AVE SUITE 100
BOERNE TX
78006-3213
US

IV. Provider business mailing address

745 W SAN ANTONIO AVE SUITE 100
BOERNE TX
78006-3213
US

V. Phone/Fax

Practice location:
  • Phone: 210-236-9372
  • Fax: 210-251-3237
Mailing address:
  • Phone: 210-236-9372
  • Fax: 210-251-3237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberN3322
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: